Toward the Tipping Point

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TOWARD THE TIPPING POINTWHO-HCWH Global Initiative toSubstitute Mercury-Based MedicalDevices in Health CareA Two-Year Progress Report

In association with the UNDP GEF Global Health Care Waste Project


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II discussion draftToward The Tipping Point|WHO-HCWH Global Initiative to Substitute Mercury-Based Medical Devices in Health CareA Two-Year Progress Report Published by the World Health Organization and Health Care Without Harm

This report, and the tremendous advances it chroni-cles, would not be possible without the dedicationand hard work of tens of thousands of nurses, doc-tors and other health professionals from around theworld who are committed to making their institu-tions and facilities mercury-free.

Written by: Joshua Karliner

With contributions from: Anu Agarwal, RaviAgarwal, Fernando Bejarano, Shu-Ti Chiou, YvesChartier, Jorge Emmanuel, Rico Euripidou, FayeFerrer, Silvia Ferrer, Jamie Harvie, Ashley Iwanga,Anja Leetz, Elena Lymberidi, Alejandra Livschitz,Nomcebo Mvelase, Veronica Odriozola, Peter Orris,Lisette van Vliet, Susan Wilburn

Co-published by: the World Health Organizationand Health Care Without Harm in association withthe UNDP GEF Global Health Care Waste Project

(www.gefmedwaste.org).

Funding for activities discussed in this reportcomes froma broad and diverse set of institutions,including: The United States EnvironmentalProtection Agency, the Swedish ChemicalsInspectorate, the United Nations EnvironmentProgramme, the UNDP GEF Project on HealthcareWaste, the Skoll Foundation, the Oak Foundation,

the Marisla Foundation, the Deshpande Foundation,the Swedish Society for Nature Conservation, theSigrid Rausing Trust, the Garfield Foundation, theZero Mercury Working Group, and IPEN (theInternational POPs Elimination Network), as wellas the thousands of hospitals, health systems andgovernment agencies expending human and finan-cial resources to implement mercury substitution.

Design and Layout by: Winking Fish

June 2, 2010

About the Global Initiative

The WHO-HCWH Global Initiative is a component of the UNEP Mercury

Products Partnership, which is led by the United States Environmental

Protection Agency.

The Objective of the WHO-HCWH Global Initiative to Substitute Mercury-Based

Medical devices is to:

By 2017, phase out the demand for mercury-containing fever thermometersand sphygmomanometers by at least 70% and to shift the production of all

mercury-containing fever thermometers and sphygmomanometers to accurate,

affordable, and safer non-mercury alternatives.

About the Initiative Co-leads:

The World Health Organization (WHO),

the international agency within the

United Nations system responsible for

health, has a number of programmes

that address the threats posed by environmental pollutants. These programmes

provide information and guidelines for risk assessment and management, for

preventing human exposure and for improving the diagnosis, treatment and

surveillance of health effects.

The Department on Public Health and Environment (PHE) and Regional

Offices are committed to helping member states to achieve safe, sustainable

and health-enhancing human environments, protected from biological,

chemicaland physical hazards, and secure from the adverse effects of global

and local environmental threats. They facilitate the incorporation of effective

health dimensions into regional and global policies affecting health and

environment, and into national development policies and action plans for

environment and health, including legal and regulatory frameworks governing

management of the human environment.

Health Care Without Harm (HCWH) is an international

coalition of more than 400 organizations in 52 countries

working to transform the health care sector so it is no longer

a source of harm to people and the environment. HCWH

has offices in the United States (Washington DC, Boston

and San Francisco), the European Union (Brussels), SouthAmerica (Buenos Aires), and South East Asia (Manila).

HCWH also has close programmatic partnerships with organizations working on

these issues in the African Region (in Durban, South Africa, Dar es Saalam,

Tanzania) and in the South Asian Region (Delhi, India).

HCWH has been working since the mid-1990s to promote the reduction and

phase-out of sources of mercury pollution from the healthcare sector in

collaboration with hospitals, health care systems, health care workers, other

NGOs, medical device suppliers, government ministries and international

agencies.

www.mercuryfreehealthcare.org

Acknowledgements


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Toward The Tipping Point|WHO-HCWH Global Initiative to Substitute Mercury-Based Medical Devices in Health CareA Two-Year Progress Report Published by the World Health Organization and Health Care Without Harm

1discussion draft

Executive Summary ........................................................................................2

Introduction ...................................................................................................4

Mercury in Health Care .................................................................... 4

The Global Initiative for Mercury-Free Health Care .............................. 5

Affordability of Alternatives .............................................................. 7

Progress in Meeting Short-Term Objectives .....................................................8

Objective 1: Standards .................................................................... 8

Objective 2: National Policies in Asia, Africaand Latin America ...................................................................... 8

Objective 3: Mercury Blood Pressure DevicePhase-out in the European Union ............................................... 10

Objective 4: Mega-City Health SystemMercury Phase-outs ................................................................... 11

Objective 5: 1,000 Hospitals Committedto Going Mercury-Free ............................................................... 12

Objective 6: Pilots in 10 New Countries .......................................... 13Objective 7: Create a Global Training Kit for Hospitals ...................... 16

Objective 8: Support Management of Mercury Wastefrom Hospitals .......................................................................... 16

Objective 9: Promote Production of Alternatives ............................... 18

Accuracy of Alternatives................................................................. 19

Objective 10: Assess Progress ........................................................ 20

Conclusion ..................................................................................................21

References ..................................................................................................23

Global Initiative Members.............................................................................25

Contents


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2 discussion draftToward The Tipping Point|WHO-HCWH Global Initiative to Substitute Mercury-Based Medical Devices in Health CareA Two-Year Progress Report Published by the World Health Organization and Health Care Without Harm

The WHO-HCWH Global Initiative to SubstituteMercury-Based Medical devices with safer, affordable andaccurate alternatives was initiated in July 2008 andlaunched in Delhi, India in December 2008.

This initiative is based on the 2005 WHO Policy Paperwhich calls for short, medium and long-term steps to achievethe gradual substitution of mercury-based medical devices.1

It is also grounded in Health Care Without Harms morethan ten years of experience working with the health caresector and national governments in North America, Europe,

Asia, Africa and Latin America to successfully achievemercury substitution.

A component of the UNEP Mercury Products Partnership,led by the U.S. Environmental Protection Agency, theInitiatives goal is:

By 2017, to phase out the demand for mercury-containing fever thermometers and

sphygmomanometers by at least 70% and to shift

the production of all mercury-containing fever

thermometers and sphygmomanometers to accurate,affordable, and safer non-mercury alternatives.

Executive Summary

Mercury-free health care is increasinglybecoming the status quo in many countries.


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3discussion draft Toward The Tipping Point|WHO-HCWH Global Initiative to Substitute Mercury-Based Medical Devices in Health CareA Two-Year Progress Report Published by the World Health Organization and Health Care Without Harm

Progress in Reaching 3-Year Objectives

Standards: WHO is developing a guidancedocument which will provide technical

advice to Ministries of Health recommendinghow to evaluate non-mercury thermometersand blood pressure measuring devices.

National Policies in Asia, Africa and

Latin America: National policies havebeen issued and are being implemented inArgentina and the Philippines, while SouthAfrica is conducting a SituationalAssessment to examine the feasibility ofsuch a policy. Several other countries arealso considering or in the process of

creating national policies.

Mercury Blood Pressure Device Phase-

out in the European Union: The EU hasprohibited sphygmomanometers for sale tothe general public. The EU is nowconsidering phasing-out sphygmomano-meters for clinical use.

Mega-City Health System Mercury

Phase-outs: To date, four mega-cities,Buenos Aires, New Delhi, Mexico City and

So Paulo are implementing mercuryphase-outs in their public health systems.

1,000 Hospitals Committed to Going

Mercury-Free: The target has beensurpassed. More than 5,600 hospitals inAsia, Africa and Latin America are in theprocess of switching, or have alreadysubstituted their mercury thermometersand blood pressure devices.

Pilots in 10 New Countries: The targethas been surpassed. New pilot projects

exist or are in the process of being createdin 14 countries.

Create a Global Training Kit for

Hospitals: HCWH has created and is in theprocess of testing a global training kit.

Support Management of Mercury Waste

from Hospitals: A series of initiatives areunderway in various countries to promotesystematic management of mercury wastefrom healthcare and other sources.

Promote Production of Alternatives:A series of meetings, market analyses andother initiatives have been undertaken witha focus on the large producersChina andIndia. A plan to promote industrialtransition will be developed.

Assess Progress: In addition to this report,an assessment of Medium-Term, 6 YearObjectives will be undertaken and theseObjectives will be refined by mid-2011.

Momentum is growing and mercury-free

health care is increasingly becoming the

status quo in many countries. The Global

Initiative is moving closer to a tipping point

that will shift the dynamics of supply and

demand in the global thermometer and

blood pressure device markets away from

mercury and toward the alternatives.

Actions by hospitals, health care systems and governments around the world have put the

Initiative on track or ahead of schedule to reach each of its Short-Term, 3-Year Objectives:


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Mercury in Health CareMercury is one of the worlds most ubiquitous heavy metal neu-rotoxicants. The United Nations Environment Programme(UNEP) and World Health Organization have identified the

adverse effects of mercury pollution as a serious global environ-mental and human health problem.2 The UNEP GoverningCouncil has targeted reducing methyl mercury accumulation inthe global environment as a major global priority.3 In February2009 the worlds governments agreed to establish anIntergovernmental Negotiating Committee to prepare a globallegally binding instrument on mercury.

Mercury has been extensively used in health care since

antiquity. It has been an integral part of many medical devic-es, most prominently thermometers and blood pressure devic-es (sphygmomanometers). In recent decades this has led to aparadox: around the world, institutions and professionalswhose mission is to heal and promote health, have been con-tributing to a significant global environmental health prob-lemmercury contaminationthrough the use of their

health care instruments.

In response to growingawareness of the health impli-cations of mercury exposure,in the first decade of this cen-tury the health sector in theU.S. largely phased out mercu-ry thermometers. Many U.S.

hospitals no longer purchase

mercury sphygmomanometers,and as of 2008, more thanone-third of the U.S. popula-tion lived in states that havebanned or severely restrictedtheir sale and/or use.4Similarly, the European Unionprohibited mercury thermometers

in 2007 and is considering similar strictures for sphygmoma-nometers. Nations such as Sweden have almost completelyphased-out mercury. Unfortunately, despite some outstandingefforts in a growing list of countries, the health sector in muchof the rest of the world still uses mercury-based medical devices.

However, in recent years, several developing countries haveinitiated a shift toward mercury-free health care. These coun-

tries have responded to policy guidelines issued by the WorldHealth Organization. Many are conducting their activitiesunder the umbrella of the WHO-HCWH Global Initiative tosubstitute mercury-based medical devices. They have also beenconvinced of the technical and economic viability of the alter-natives. Most notably, the ministries of health in bothArgentina and the Philippines have issued national policiesphasing-out mercury-based medical devices. Health care sys-tems in countries around the globe, including India, Nepal,

South Africa, Tanzania, Mexico, Chile, Costa Rica and Brazilalso have launched programs to demonstrate and expand mer-cury-free health care.

Introduction

Mercury sphygmomanometer

Mercury has been extensively used in health care since antiquity.


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The Global Initiative forMercury-Free Health CareHealth Care Without Harm and the World HealthOrganization are co-leading a global initiative to achieve virtu-

al elimination of mercury-based thermometers and sphygmoma-nometers over the next decade and their substitution withaccurate, economically viable alternatives.

This initiative is based on the 2005 WHO Policy Paper,which calls for short, medium and long-term steps to achievethe gradual substitution of mercury-based medical devices.5 It isalso grounded in Health Care Without Harms more than ten

years of experience working with the health care sector andnational governments in North America, Europe, Asia, Africaand Latin America to successfully achieve mercury substitution.

This project is a component of the UN EnvironmentProgrammes (UNEP) Mercury Products Partnership, which isled by the U.S. Environmental Protection Agency. This broad-er UNEP Products Partnership seeks action to eliminate mer-cury in products such as batteries, lighting and lamps, electricaland electronic devices, dental products, and measuring andcontrol devices.

The UNEP Products Partnership is in turn part of a larger

global effort to address the toxic environmental health impactsof mercury accumulation in the global environment. This effortconsists of a series of other voluntary partnerships in areas ofmajor mercury emissions, such as chlor-alkali production, arti-sanal gold mining, coal fired power plants, and mercury wastemanagement.

The Global Initiative is on track or ahead of schedule

in achieving its objectives.

Nurses in Argentina receive their firstdigital thermometers.


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UNEP has also been charged by the worlds governments tofacilitate the negotiation of an internationally legally bindinginstrument to address mercury pollution.

With specific regard to the WHO-HCWH GlobalInitiative, the Products Partnership has set the following

objective:

By 2017, to phase out the demand for mercury-containing feverthermometers and sphygmomanometers by at least 70% and to shiftthe production of all mercury-containing fever thermometers andsphygmomanometers to accurate, affordable, and safer non-mercuryalternatives.

The Initiative is based on experiences with the healthcare sec-tor over the past decade, and is premised on the understandingthat a well-planned and appropriately funded initiative shouldbe capable of achieving global virtual elimination of mercuryfever thermometers and blood pressure devices in health careinstitutions within the next decade. In order to achieve this,five core strategies have been identified.

1. Establish an international mechanism to certify the accuracyand efficacy of mercury-free alternative medical devices.

2. Continue to expand awareness-raising and mobilization of

the health care sector in all countries, including actorsinvolved in health care emergency responses, in order toshift demand towards alternative devices and educatesocieties about the broader impacts of mercury.

3. Support the development of model policies and catalyticactivities that leverage resources to shift demand at global,

regional, national, state and municipal levels.

4. Define safe elimination strategies for existing mercuryequipment. Develop and implement interim and long-termmercury waste management plans at the health care sector,national and regional levels.

5. Support the establishment and/or adequate expansion ofproduction facilities for mercury-free fever thermometersand other medical devices in developing countries, with anemphasis on encouraging substantial production in Chinaand/or India.

With this framework established, most ongoing work to sub-stitute mercury-based medical devices around the world wasincorporated into the Global Initiative as it began in July 2008.The Initiative was formally launched in Delhi, India in

December 2008.

In order to promote this effort and chart achievements,WHO and HCWH have established a website that serves as aglobal information clearinghouse on mercury and healthcare(www.mercuryfreehealthcare.org).

A membership structure, which parallels the UNEP prod-

ucts partnership, was also established. More than 60 leadinghospitals, professional associations, local governments andNGOs from around the world have joined this effort asFounding Members or Partners (see p. 25).

The Global Initiative also established a series of Short Term

Objectives (3 yearsJuly 2008 July 2011) and Medium TermObjectives (6 yearsto be achieved by July 2014) as bench-marks by which to measure progress. This report reviews the

progress of hospitals, health care systems and governmentswhose actionstaken both formally as part of the Initiativeand in conjunction with or parallel to itare contributing tothe achievement of its Short Term Goals.


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Affordability of Alternatives

Many healthcare practitioners are concerned about the availability of alternatives. In fact, thereare many mercury-free thermometers and sphygmomanometers available from major medical

equipment suppliers who service the global market.6

With limited healthcare budgets, many health care systems and hospitals today still face thechallenge of deciding between a mercury device and its alternative. Those facilities with limitedbudgets have been able to successfully avoid this road block through operational strategies.

For example, when planning future budgets, hospitals are including the expense of frequentmercury thermometer breakage when calculating annual costs. In many cases, the cost ofpurchasing more durable digital or mercury-free alternatives is comparable to or less than thereplacement cost of mercury thermometers over a year period.

The Hospital Posadas in Buenos Aires, Argentina pursued just such a strategy and reported

significant savings when it replaced all of its thermometers. Between April and June 2006, this450 bed hospital purchased 3,152 mercury thermometers. A year later, during the same period in2007, it purchased 355 mercury thermometers and 188 digital devices. The cost savings totalednearly U.S. $3,000.

At the Federico Gomez Childrens Hospital in Mexico, it is estimated that this 250 bed institutionwill save a minimum of U.S. $10,000 over six years when replacing mercury thermometers. Thisestimate includes the costs of digital device and battery replacement, as well as mercury andbattery disposal.7

In the Hospital So Luiz in So Paulo, Brazil, a 116 bed hospital, health care officials found thatthe costs of maintenance and calibration of digital and aneroid thermometers and

sphygmomanometers were significantly lower than the costs of maintaining existing mercurydevices. In fact, they determined if they were to replace all sphygmomanometers, wallthermometers and clinical thermometers in the hospital with alternative devices, that the savingson maintenance and calibration would pay back the initial capital investment of more than U.S.$9,000 in five years, while saving another U.S. $2,000 a year after that.8

In India, the NGO Toxics Link, a Founding Member of the Global Initiative, reports that a studyin a few hospitals has shown that the recurring cost with mercury instruments far exceeds thiscost difference [with non-mercury instruments] in addition to the extra environmental andoccupational hazard cost.9

Hospitals can actually save money by substituting mercury-based

medical devices with safe alternatives.


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The Global Initiative, developed in July 2008 and

formally launched in New Delhi in December of that

year, set out 10 Short Term Objectives to be

completed by July 2011. The following is an update

on progress in reaching these Objectives to date:

Objective 1: StandardsIdentify and/or establish internationalstandards for mercury-free alternativemedical devices.

Status: In Process and On Track

Description of Activities: WHO is developing a guidance

document that will provide practical technical advice toMinistries of Health to evaluate and compare thermometersand blood pressure measuring devices. The document will drawon a series of standards already used by several governments indifferent parts of the world.

Next Steps: The document will be developed in 2010,reviewed by relevant parties at WHO, and once approved,distributed to Ministries of Health and as a web-baseddocument.

Objective 2: National PoliciesEstablish and implement national policiesto phase-out mercury-based medicaldevices minimally in one country each inAsia, Africa, and Latin America.


Description of Activities:

Philippines: National Policy EstablishedImplementationin Process In late July 2008, the Department of Health(DOH) of the Philippines issued Administrative Order 21 tophase-out all mercury-based medical devices in the country

over a two year period.10 Since the announcement, HCWH SEAsia and WHO Philippines have been working with the DOH

Progress in MeetingShort Term Objectives

The Philippines was the first developing country to establish anational policy to phase-out mercury-based medical devices.


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and many individual hospitals and professional associations toassure successful implementation of the Administrative Orderin the Philippines more than 1,800 hospitals. More recently,the Secretary of Health has called for a stronger measure ban-ning the import of mercury containing medical devices.11

Argentina: National Policy EstablishedImplementation inProcess In February 2009 Argentinas Minister of Healthissued a resolution advising the health sector to refrain frompurchasing new mercury-based medical devices. This resolutionestablishes the policy and purchasing guidelines required for thephase-out of mercury thermometers and blood pressure devicesin the more than 1,700 hospitals in the country.12 It is estimat-ed that the reduction in global mercury emissions from ther-

mometers alone from a fully implemented national policy willbe 1 metric ton per year.13

In February 2010, the Minister of Health issued a secondresolution, strengthening and deepening the 2009 resolution byprohibiting the production, import, sale or free transfer of mer-cury column blood pressure sphygmomanometers to be used bythe general population, medical doctors or veterinarians.

Imports were to be halted immediately, and all sales will ceasewithin six months.14

South Africa: National Situational Assessment to Begin Global Initiative Founding member, groundWork, a SouthAfrican NGO, reports that the countrys Ministry of Health andDepartment of Environmental Affairs are undertaking a situa-

tional assessment to examine the feasibility of replacing mercu-ry devices nationally.

Next Steps: Encourage and Support Other Countries MovingToward National Policies:

Costa Rica: The Caja Costarricense del Seguro Social(CCSSCosta Rican Social Security Institute), which runs all29 public hospitals in the country, adopted a Directive on thepurchase of mercury thermometers which stipulates that mercu-ry devices should be avoided.15 The CCSS is currently movingto substitute mercury-based medical devices throughout its sys-

tem. This is the first step in developing a potentially more far-reaching national policy on mercury in health care.

Argentina ordered a phase-out of mercuryin health care in 2009 and banned mercury

sphygmomanometers in 2010.

Argentina and the Philippines are both implementing

national policies to phase-out mercury medical devices.

Several other countries are following suit.


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India: In March 2010, the Directorate General of HealthServices of Indias Ministry of Health and Family Welfareadvised all Central Government Hospitals and Health Centers,to gradually phase out mercury containing equipments (ther-mometer, BP Instruments etc.) and replace them with goodquality non-mercury equipment, in order to prevent the toxiceffects of mercury on patients and health care workers.16

Global Initiative Founding Member, the NGO Toxics Link,

reports that these guidelines, which apply to roughly 1,669 hos-pitals and 174,000 primary clinics and health centers, havebeen circulated to all the Ministries under the Government ofIndia that run health establishments, including the Ministry ofHealth, Ministry Of Defence, Ministry of Home Affairs,Ministry of Labour, Ministry of Railways, Ministry of Women &Child Development and Ministry of Panchayati Raj. Theseguidelines have the potential to evolve into a broader national

policy on mercury in health care.

Taiwan, China: In March 2008, the Environmental ProtectionAdministration announced a national policy to phase-out mer-cury thermometers. The Official Announcement prohibited the

issuance of new licenses to import mercury ther mometers andbanned their sale to the public as of July 2008. A ban on the

sale of mercury thermometers to medical establish ments is slat-ed to go into effect in July 2011.17 While mercury sphygmoma-nometers are still not prohibited, authorities report that themajority of health care organizations are now adopting elec-tronic blood pressure measuring devices, as Taiwan, China isone of the largest global manufacturers of these devices, makingthem affordable.18

Uruguay: In January 2009, the Ministry of Health announcedthat it was phasing-out mercury thermometers for use in healthcare and private homes.19

Objective 3: SphygmomanometerPhase-out in the EUAchieve the phase-out of mercurysphygmomanometers in the EuropeanUnion.

Status: In ProcessDescription of Activities:In September 2007, the EUbanned the sale of mercury thermometers for use in health care.The ban went into effect in April 2009.20 Under this Europe-wide legislation, mercury sphygmomanometers and other mea-suring devices are also banned for sale to the general public.The EU is now considering phasing-out sphygmomanometersfor clinical/professional use.

A recent report by the EU Scientific Committee on Emergingand Newly Identified Health Risks, under the DirectorateGeneral for Health and Consumers of the European

Commission, found that there is no evidence of adverse effectson patients health in clinical settings due to the replacementof mercury containing sphygmomanometers by validated mercu-ry-free alternatives.21 This has set the stage for a phase-out of

mercury-sphygmomanometers in the European Union.

Digital sphygmomanometer

The stage is set for a phase-out of mercury

sphygmomanometers in the EU.


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Next Steps:The European Chemicals Agency, at the requestof the EC, intends to submit a proposal for restricting the use ofmercury sphygmomanometers in health care under theEuropean chemicals law REACH Restrictions Process, Article69(6). Expected date of submission is June 15, 2010. 22 This sub-

mission will lead to a series of comments and inputs from inter-ested parties, and decisions from relevant Chemical Agency andEuropean Commission bodies that may result in a final decision

being taken in early 2012 to ban mercury sphygmomanometersin the EU. The European Environmental Bureau, HCWHEurope and the Health and Environment Alliance have provid-ed significant technical and policy input for the European dis-cussions, and will continue to closely follow this process.

Objective 4: Mega-CityMercury Phase-outsReplicate the municipal policies of Buenos

Aires and Delhi in 3 other developingcountry megacities.



Buenos Aires, Argentina:In July 2006, the Ministry ofHealth of the City of Buenos Aires, which at the time waspurchasing 40,000 mercury thermometers a year, issued aLetter of Intent to gradually and progressively eliminate mer-cury from the 33 hospitals and 41 clinics under its supervi-sion. Since that time, this, the largest health care system in

the country, has phased out mercury in most of its hospitalsand has taken mercury thermometers and blood pressuredevices off its purchasing lists.

Delhi, India:As a result of a policy issued by the DelhiDepartment of Health and Family Welfare in 2007, all 73 gov-ernment-run hospitals have stopped purchasing new mercury-based medical devices, and a total of 2,229, mostly small

healthcare establishments in the National Capital Territory ofDelhi are in the process of replacing mercury devices. Severalprivate systems and philanthropic hospitals in Delhi have alsoreplaced mercury.23

All 73 government-run hospitals in Delhihave stopped purchasing new mercury

medical devices.

Four mega-citiesBuenos Aires, Delhi, Mexico City and So Paulo

are phasing out mercury in their health systems.


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Mexico City, Mexico:In2009, the Mexico FederalDistrict (Mexico City)Health Secretariat formallyjoined the WHO-HCWHJoint Initiative and com-mitted to mercury phase-

out in its entire public

health system, which iscomprised of 29 major hos-pitals and 230 primary careclinics serving five millionpeople.24 Based on 2009figures when the systempurchased 57,000 mercurythermometers, the switch

to alternatives will preventthe release of more than 57kg mercury/year from thermometers alone.

So Paulo, Brazil: The City of So Paulo is the first in Brazil

to eliminate the use of devices containing mercury in its publichospitals. To date, 162 hospitals/emergency rooms in the public

and private sector in So Paulo have completely substitutedmercury devices. Another 117 primary health care centers,hundreds of laboratories, blood banks and medical specialtycenters have also made the switch, making the total 517 healthentities that are now mercury-free.25 While there is no formalpolicy, the Municipality of So Paulo and its related healthinstitutions have relied on the tireless work of one individual inthe Ministry of Labor there, Dr. Cecilia Zavariz, who has spear-headed this effort.26

Next Steps:Support implementation in Mexico City and rep-licate these models in other mega-cities globally.

Objective 5: 1000 HospitalsCommit To Go Mercury-freeEstablish the commitment to, or activitiesdesigned to, phase out mercury-basedmedical devices in 1,000 hospitals in Asia,Africa, the Americas and Europe.

Status: Target Surpassed


NUMBER OF DEVELOPING COUNTRY HOSPITALS*COMMITTED OR ALREADY MERCURY-FREE**

Argentina 1722 ***

Brazil 162

China 3

Chile 16

Costa Rica 5

India 1742 ****

Mexico 40

Philippines 1847 ***

South Africa 127

Total 5664

*Health centers and clinics not included

**Partial list based on available information, the true number of countries and hos-pitals is likely much greater

***Assumes that all hospitals in the country have been committed to phase-out vianational policy

****Assumes all Central Government hospitals committed through national guide-lines, plus Delhi city hospitals; does not include private sector

Next Steps:Continue to build and expand the number ofhospitals around the world.

Mexico City formally joined the Initiative, committing 29hospitals and 230 primary care clinics serving 5 million

people to mercury-free health care.


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Objective 6: Pilots in10 New CountriesEstablish demonstration pilots in 10 newcountries.

Status: Target Surpassed

Description of Activities: Pilot projects, demonstrating theviability of mercury-free health care, are underway or set tobegin in 14 countries. Some of these are funded, others stillrequire funding.

1. Brazil:While So Paulo has excelled in substituting mercu-ry-based medical devices, much of the rest of Brazil has yet totake action. A pilot project in Rio de Janeiro is currently beingestablished by HCWH, in collaboration with health authoritiesand NGOs, with financial support from U.S. EPA.

2. Chile:The Ministry of Health and the National

Environmental Commission collaborated with HCWH, withfinancial support from U.S. EPA, to establish three pilot hospi-tals in 2008-09. The success of these efforts have resulted inmore than 16 hospitals in the country committing to gomercury-free.

3. China: In 2007, Chinas environmental agency, SEPA, part-nered with U.S. EPA to conduct mercury inventories anddevelop plans for phase-out in two hospitals in Beijing.27 Sincethat time, three hospitalsBeijing Tiantan Hospital, BeijingJishuitai Hospital and Blood Disease Hospital of China MedicalScience Institutehave taken steps to educate personnel andsubstitute mercury devices with alternatives.28 In 2010, WHO is

preparing to work with authorities in China, as part of a Greenand Safe Hospitals Project, to pilot mercury substitution in 3more hospitalsthe First Hospital of Jilin University,

Nanchangs Third Hospital, and the Second Peoples Hospitalof Panzhihua.

With three hospitals in China movingto substitute mercury, WHO is working with the

government to pilot three more.

Hospitals in fourteen new countries have begun or are set to begin

piloting mercury-free health care in the coming year.


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4. Costa Rica: In Costa Rica, the National Childrens Hospitalsuccessfully piloted mercury-free health care in 2008-09. Thereare two more pilots coming online in 2010 as part of an effortto promote broader national replication. HCWH is supportingthe Costa Rican governments effort as needed. U.S. EPA has

provided funding.

5. Ecuador:The Quito-based Institute for the Development ofProduction and the Work Environment, and the Lowell Centerfor Sustainable Production at the University of Massachusetts,are working together to assist two pilot hospitals in reducing useof mercury-containing products and improving management of

mercury-containing waste. U.S. EPA has provided funding.

6. Latvia:As a component of the UNDP GEF Project onHealth Care Waste, in which WHO and HCWH are PrincipleCooperating Agencies, two hospitals, Rezekne and VentspilsHospitals, have been identified, and work is beginning to sub-stitute mercury-based medical devices as part of a broader sus-

tainable health care waste management effort.29

7. Lebanon: The Ministry of Environment will work with twohospitals, one medical laboratory and one clinic to substitutemercury-based medical devices as part of a broader sustainablehealth care waste management effort. This pilot demonstrationis a component of the UNDP GEF Project on Health CareWaste, in which WHO and HCWH are Principle CooperatingAgencies. The project includes a review of existing policies and

recommendations regarding mercury use.

8. Nepal: WHO is working with the Ministry of Health,Initiative Founding Member, the Health Care Foundation ofNepal and CEPHED to establish a project in a hospital inKatmandu to model mercury substitution. Funding is providedby U.S. EPA.

9. Nicaragua: The Nicaraguan Ministry of Health has agreedto develop at least one pilot hospital project in 2010. Full fund-ing is not yet secured.

10. Senegal: The Directorate of Environment and ClassifiedEstablishments, along with the National Program for the

Control of Nosocomial Infections of the Ministry of Health, areworking with a major urban hospital (Grand Yoff GeneralHospital in Dakar), Rufisque district hospital and a small ruralhealth post to phase-out mercury and demonstrate non-mercurydevices. This activity is part of a broader effort on sustainablehealth care waste management under the UNDP GEF Projecton Health Care Waste, in which WHO and HCWH are

Principle Cooperating Agencies.

11. Syria: The Environmental Protection & SustainableDevelopment Society, a Syrian NGO, has initiated a pilot proj-ect to substitute mercury-based medical devices in one hospitalin Damascus. The effort has seed funding from IPEN.

12. Tanzania:WHO and the Ministry of Health have signedan agreement to pilot mercury-free health care in a hospital inthe Bagamoyo District. Funding comes from U.S. EPA. GlobalInitiative Founding Member AGENDA is also working withsupport from SSNC to develop at least one other pilot projectin the country.

13. Thailand: The Bureau of Environmental Health ofThailands Ministry of Public Health is implementing a GREENand CLEAN Hospital Project in twelve regional Health

Several hospitals in Costa Rica have switched to alternatives.


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Promotion Hospitals. All of these hospitals will pilot mercury-free health care.30

14. Vietnam:As a component of the UNDP GEF Project onHealth Care Waste, in which WHO and HCWH are PrincipleCooperating Agencies, one urban hospital, a provincial hospi-

tal, and a cluster of rural health facilities have been identified,and work will begin soon to substitute mercury-based medicaldevices as part of a broader sustainable health care waste man-agement effort.

Next Steps: Assure that pilots are well-established, viable,and able to catalyze broader replication. Continue to expandthe number of pilots.

The UNDP GEF Health Care Waste Project ispiloting mercury substitution in Lebanon, Latvia,

Vietnam and this major urban hospital in Senegal.

Pilot hospitals can set the stage for national replication.


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Objective 7: Global Training ModuleDevelop and globally distribute a trainingmodule focused on substituting mercury-based medical devices; conduct additionaloutreach and educational activities.


Description of Activities:HCWH Latin America has cre-ated a Global Training Toolkit. It is currently being tested withHCWH partners in the region.

Next Steps: The Toolkit will be modified, based on early feed-back, and then distributed more widelyfirst in Latin America

and then globallyto allow for broad replication and scaling-up of mercury-free initiatives around the world. The UNDPGEF Health Care Waste Project will also adapt the trainingmodule as part of the national training programs being devel-oped in seven countries.

Objective 8: Mercury WasteManagement Projects in Health CareEstablish vis--vis the Basel ConventionSecretariat, model national health caremercury waste management projects, andpromote their replication.

Status: In Process

Description of Activities: The switch from mercury-baseddevices to alternatives is beginning to significantly reduce thehealth sectors annual production of mercury waste, generatedby the daily breakage of thousands of thermometers and blood

pressure devices.

Yet many hospitals making the switch find themselves withsurplus mercury thermometers and sphygmomanometers. Giventhe lack of hazardous waste management infrastructure in manycountries, hospitals often have no other option but to storeobsolete mercury-based devices on-site. In this context, safe

storage within health carefacilities is being promoted,while methods for a morecentralized interim safe stor-age are being developed.

The UNEP Secretariatof the Basel Convention isreceiving funding from the

U.S. EPA to developapproaches and nationalplans for managing mercu-ry waste in Latin America,with an emphasis on mer-cury waste from the health

care sector. The projectswill consist of training, inventories, technical advice to set uplow cost, temporary mercury storage, and development ofnational plans for the environmentally sound management ofmercury waste. In addition to the activities of the BaselCenter, various other initiatives are underway.

For instance, the City of Buenos Aires is storing its hospi-tals mercury-based medical devices securely in the citys waste

facility, as the city governments environmental authoritiesdevelop a longer-term solution for all of the citys mercurywaste.31 In the Philippines, hospitals storing mercury wasteonsite are urging the Department of Environment and NaturalResources to develop and implement a national plan for mercu-ry waste management.

Additionally, as a component of the UNDP GEF Project on

Health Care Waste, in which WHO and HCWH are PrincipleCooperating Agencies, initial guidelines are being developed toassist hospitals in Argentina, India, and the Philippines on require-

ments for temporary on-site storage, transportation, and centralizedintermediate storage of mercury waste from health facilities.

Next Steps:As mercury phase-out in the health sector andbeyond begins to gain momentum, mercury storage and wastemanagement plans, as well as infrastructure, will need to bedeveloped in every country. This goes beyond the scope of thisInitaitive and for that matter of the health sector, but is essen-tial to achieving full elimination of mercury in health care andin the broader societal context.

The switch to alternatives is reducing the health sectors

annual production of mercury waste.


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Storage of mercury devices has traditionally failed totake into account their toxic nature.

Today, various initiatives are underway topilot safe managment of remaining mercurywaste in health care facilities.


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Objective 9: PromoteProduction of AlternativesDevelop a plan of action to establishand fund the development of productionfacilities for high quality, affordablemercury-free medical devices in

developing countries.

Status: In Process

Description of Activities: While a plan of action has yetto emerge, dialogues have been initiated in both India andChina. In India, WHO, HCWH and Toxics Link held aBusiness Roundtable in December 2008 to discuss Indiaspotential to become a world leader in producing mercury-freemedical devices. Subsequently a market study was produced.32Substantive follow-up by Indian industry is pending.

China is by far the single largest global producer and sup-plier of mercury thermometers and blood pressure devices, as

well as the alternatives.33 Yet to date only a handful of hospi-tals have gone mercury-free.34 Discussion of how Chinashealth sector and medical devices industry can together pro-vide leadership in the global transition to mercury-free healthcare is moving forward.

Next Steps: The growing move toward mercury-freehealth care around the world is shifting market demandaway from mercury-based medical devices and toward alter-natives. As this effort builds momentum, it will, in turn,shift production in the main manufacturing centers away

from mercury devices and toward the alternatives as well.As this shift continues to evolve, this Initiative will developa plan of action to support a broad industrial transition

toward alternatives production.

China, the single largest producer of both mercury devices

and alternatives, can lead the global manufacturing transition.


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Accuracy of Alternatives

Some medical professionals still consider mercury to be the only accurate and consistent method ofmeasuring temperature and blood pressure. Yet, as peer reviewed studies demonstrate, this is not thecase, and in fact widespread faith in the accuracy of mercury thermometers and sphygmomanometerswas probably overly positive in years past.

As with most products (mercury or mercury-free) the accuracy of digital thermometers, the mostcommonly used mercury-free temperature device, is dependent on manufacturing quality andtechniques. Standards organizations like ASTM International have developed protocols that will helpthe healthcare community identify accurate alternatives.35 It is imperative that the healthcarecommunity and governments purchase thermometers from manufacturers who follow techniques andtesting protocols independently certified by ASTM or other internationally established regimes, toensure the accuracy of these devices.

Sphygmomanometers represent the largest reservoir of mercury in current medical use. As withthermometers, mercury and non-mercury blood pressure devices provide accurate measurement as longas both instruments are calibrated. Examples of both inaccurate mercury and mercury-freesphygmomanometers can be found in the medical literature, though this inaccuracy is typically relatedto poor maintenance and calibration.36 A large number of scientific studies have concluded thatmercury-free measuring devices produce the same degree of accuracy as mercury devices, providedthey are properly maintained and calibrated.37

A recent report by the Committee on Emerging and Newly Identified Health Risks, under theDirectorate General for Health and Consumers of the European Commission, found that mercury-freeblood pressure measuring devices (when clinically validated) are generally reliable substitutes formercury-containing sphygmomanometers in routine clinical practice. It also concluded that there isno evidence of adverse effects on patients health in clinical settings due to the replacement of

mercury containing sphygmomanometers by validated mercury-free alternatives. The report furtherfinds that mercury-based sphygmomanometers are not essential for calibration.38 Therefore, due tothe acute toxic hazard to health care workers and chronic hazard to society, these devices have noplace in clinical care.

Switching to mercury-free sphygmomanometers in clinical settings has not caused any reportedproblems in clinical diagnosis and monitoring in any of the Latin American countries that have phased-out mercury blood pressure devices and adequately maintained the alternatives. Meanwhile, theSwedish government has completely eliminated mercury column sphygmomanometers.39

One problem that several hospitals in developing countries have encountered as they substitutemercury-containing sphygmomanometers is that many aneroid and digital devices are of poor quality.Yet many devices currently produced satisfy the criteria of professional organizations such as the

British Hypertension Society, the European Hypertension Society and the Association for theAdvancement of Medical Instrumentation. The British Hypertension Society (BHS) has created a list ofvendors of sphygmomanometers that have met the BHS criteria and are suitable for clinical practice;this list is posted on their web site.40

The World Health Organization is in the process of preparing a guidance document that will providetechnical advice to Ministries of Health and health care systems as they select alternative, mercury-freetechnologies (See Short Term Objective One: Standards Page 8).


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Objective 10: Assess Progressand Refine Medium-term ObjectivesAssess progress after two years, refine

Medium Term Objectives, and developactivities for years 4-6.

Status: In Process

Description of Activities: Current medium term objectivesare as follows:

By 2014:

1. Assure adherence to international standards for mercury-free alternative medical devices.

2. Establish and implement national policies to phase-out

mercury-based medical devices in at least four countrieseach in Asia, Africa, and Latin America.

3. Assure the prohibition of exports of mercurysphygmomanometers from the European Union.

4. Replicate the municipal policies of Buenos Aires and Delhiin 10 other developing country megacities.

5. Establish the commitment to, or activities designed to,phase out mercury-based medical devices in 5,000 hospitalsin Asia, Africa the Americas and Europe.

6. Establish demonstration pilots in 20 new countries.

7. Globally distribute a training module focused on substitutingmercury-based medical devices; conduct additional outreachand educational activities.

8. Support the Basel Convention Secretariat as it replicatesmodel national health care mercury waste management

projects, and promote their replication.

9. Encourage new production facilities for high quality,affordable mercury-free medical devices in developingcountries to come on line.

10.Assess progress after two years; set specific targets for years

7-10.

Next Steps:Based on this report and feedback from partici-pants in the Global Initiative, WHO and HCWH will assessprogress and refine the Medium Term Objectives.

With adequate resources, the Initiative can build on success

and scale-up activities to achieve a global phase-out.


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CONCLUSION

The WHO-HCWH Global Initiative to Substitute Mercury-Based Medical devices with safer, affordable and accurate alter-natives is on track or ahead of schedule in achieving itsobjectives.

National governments, provinces, states, and municipal

health care systems in Asia, Africa and Latin America are mov-ing forward to develop and implement policies to switch tomercury-free health care.

The European Union, which has prohibited mercury ther-mometers, has developed strong scientific evidence that sup-ports an EU-wide phase-out on mercury sphygmomanometersone which can then be replicated in many parts of the world.Thousands of developing country hospitals are making the

switch, and hospitals in more than a dozen new countries arepiloting alternativesan important first step in building abroader, system-wide approach in each nation.

This progress, along with comprehensive efforts to phase outmercury-based medical devices in the U.S., have significantlyreduced the global health sectors annual production of mercurywaste, created by the daily breakage of thousands of thermome-ters and blood pressure devices. Safe storage of remaining mer-cury products within health care facilities is being promoted,while methods for more centralized longer-term storage are

being developed.

The broad goal of this Initiative is to phase-out 70% per-cent of mercury-based medical devices by 2017. While ambi-tious, this goal is also eminently achievable. It will requirehard workand the commitment of governments, ministries ofhealth, hospitals, doctors, nurses and other healthprofessionals.

Health professionals are becoming important messengers, addressing the health effects of mercury used in health care and beyond.


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Given current momentum, the global move toward mercu-ry-free healthcare should, in the next few years, reach a tippingpoint where non-mercury medical devices will become the sta-tus quo throughout the world. While this moment is still not onthe immediate horizon in many countries, it is increasingly in

the realm of possibility.

Market demand is already shifting away from mercury-basedmedical devices and toward alternatives. As this effort buildsmomentum it will, in turn, shift production in the main manu-facturing centers away from mercury devices and toward thealternatives as well. As economies of scale grow, prices for highquality non-mercury devices should continue to drop, allowing

demand for the alternatives to grow even more.

As recent progress shows, once the health sector becomesaware of the impact of its use of mercury on global environmen-tal health, as well as on worker and patient health and safety, itmoves to take action. The viability and affordability of alterna-tives not only makes this change possible, but is helping toaccelerate it.

Just as importantly, once they are actively addressing thehazards of mercury in their own sector, ministries of health andhealth care professionals often become important messengersand advocates on the broader challenges of mercury pollutionin their countries. As the worlds governments negotiate a bind-

ing treaty to control the use of mercury, there is a need for bothbroader public awareness and more far-reaching public policyon mercurys health effects. In this regard, the health sector canplay a central role.

We are moving toward a tipping point that will shift

global dynamics toward the alternatives.


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1 Mercury in Health Care, Policy Paper, World Health Organization, 2005.WHO/SDE/WSH/05.08 http://www.who.int/water_sanitation_health/medicalwaste/mercurypolpap230506.pdf

2 Exposure to Mercury: A Major Public Health Concern, World HealthOrganization, 2007, http://www.who.int/phe/news/Mercury-flyer.pdf; UNEP,Global Mercury Assessment, UNEP Chemicals, Geneva, December 2002,http://www.chem.unep.ch/mercury/report/final%20assessment%20report.htm

3 Decisions adopted by the Governing Council/Global Ministerial Environment

Forum at its twenty-fourth session, UNEP, February 9, 2007: see Decision 24/3http://www.unep.org/gc/gc24/docs/GC24_decisions.pdf

4 Jamie Harvie PE, Joshua Karliner, End of An Era: The Phase-Out of Mercury-Based Blood Pressure Measurment Devices in the United States , Health CareWithout Harm, September 2008, pp. 23-25.

5 Mercury in Health Care, Policy Paper, World Health Organization, 2005.WHO/SDE/WSH/05.08 http://www.who.int/water_sanitation_health/medicalwaste/mercurypolpap230506.pdf

6 For instance see: Guide to Alternatives for Health Care Personnel, Health CareWithout Harm, South East Asia Office, June 2007. http://www.noharm.org/details.cfm?ID=1690&type=document

7 Presentacin de Roco Gonzlez Mesa Costos de Sustitucin Termmetros

de Mercurio Hospital Infantil de Mxico Federico Gmez. Centro deAnlisis y Accin en Txicos y sus Alternativas (CAATA), Punto Focal deSalud sin Dao en Mxico, Septiembre 2007.

8 Carlos Eduardo Lima, Eng Segurana do Trabalho, Elaine Alves Anastcio,Engenheira Clnica Benefcios Advindos da Susbstituio dos Aparelhoscom Mercrio do Ponto de Vista Econmico Hospital Sao Luiz, Sao PauloBrazil, Presentation delivered at Jornada da eliminao do uso de aparelhoscom mercrio Sao Paulo, Brasil, May 3, 2007.

9 Anu Agarwal, Moving Toward Mercury-Free Health Care: SubstitutingMercury-based Medical Devices in India, Toxics Link, New Delhi, 2009. p. 3.http://www.toxicslink.org/pub-view.php?pubnum=244

10 Administrative Order 2008-0021, Gradual Phase-out of Mercury in all

Philippine Health Care Facilities and Institutions, Department of Health,Republic of the Philippines, July 30, 2008. See: http://www.mercuryfreehealthcare.org/Philippines_AO21.pdf

11 Jerry E. Esplanada, DOH calls for ban on mercury. Philippine DailyInquirer 02/22/2010. http://newsinfo.inquirer.net/breakingnews/nation/view/20100222-254730/DOH-calls-for-ban-on-mercury

12 Resolution 139/2009 Argentine Ministry of Health, Feb. 19, 2009,Public Health Plan for Minimization of Exposure to/Replacement ofMercury, published in the Official Bulletin, Feb. 23, 2009, Number: 31600,Page: 11. See: http://www.mercuryfreehealthcare.org/success.htm#nac

13 The Global Movement for Mercury Free Health Care, Health Care WithoutHarm, November 2007, p. 9. http://www.noharm.org/globalsoutheng/mercury-report-download

14 Resolution 274/2010, Ministry of Health, Republic of Argentina, February 9,2010, Prohibition of the importation, commercialization or free transfer ofmercury column sphygmomanometers, apparati for measuring aterialpressure. Expansion of the limits of current restrictions.; Published in theOfficial Bulletin February 16, 2010. See: http://www.mercuryfreehealthcare.org/Argentina_Administrative_Decision%20_274.pdf

15 Caja Costarricense de Seguro Social, CCSS avanza en la eliminacin delmercurio, www.ccss.sa.cr/html/comunicacion/noticias/2009/12/n_1100.html

16 Guidelines to Reduce Environmental Pollution due to Mercury and E-wastein Central Government Hospitals and Health Centers, issued by Dr. AnilKumar, Chief Medical Officer, Directorate General of Health Services,Ministry of Health and Family Welfare, Government of India. http://www.mercuryfreehealthcare.org/guidelines.pdf

17 Restriction of the Import and Sale of Mercury Thermometers, EPA Fei-Tzu No. 0970021484, March 26, 2008. http://law.epa.gov.tw/en/laws/229386189.html

18 Personal Correspondence, Shu-Ti Chiou, M.D., Ph.D., M.Sc. Director-General, Bureau of Health Promotion, Department of Health, Taiwan,

China, May 5, 2010.

19 Fin de termmetros en base a mercurio El Pais, Montevideo, January 30,2009. http://www.elpais.com.uy/09/01/30/pnacio_395849.asp

20 Directive 2007/51/EC of the European Parliament and of the Council of 25,September 2007, amending Council Directive 76/769/EEC relating torestrictions on the marketing of certain measuring devices containingmercury. Text with EEA relevance: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2007:257:0013:01:EN:HTML

21 Committee on Emerging and Newly Identified Health Risks, under theDirectorate General for Health and Consumers of the European Commissionon Mercury Sphygmomanometers in Healthcare and the Feasibility of Alternatives

23 September 2009. http://ec.europa.eu/health/ph_risk/committees/04_

scenihr/docs/scenihr_o_025.pdf

22 See http://echa.europa.eu/chem_data/reg_int_tables/reg_int_curr_int_en.asp

23 Anu Agarwal, Moving Toward Mercury-Free Health Care: SubstitutingMercury-based Medical Devices in India, Toxics Link, New Delhi, 2009, pp. 5,11-14. http://www.toxicslink.org/pub-view.php?pubnum=244

24 Letter from Dr. Jose Armando Ahued Ortega, Secretary of Health, MexicoFederal District, to Yves Chartier, WHO, and Joshua Karliner, HCWH,August 31, 2009. http://www.mercuryfreehealthcare.org/SSDF.pdf

References


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25 Cecilia Zavariz, Status Update of Mercury Devices Substitution in the HealthSector Sao Paulo, Brazil, January 2010, Ministry of Labor and Employment/So Paulo Regional Superintendence of Labor, published as an annex toSummary Report of Studies and Assessments on Mercury Developed inBrazil, Ministerio do Meio Ambiente, submitted to UNEP Chemicals, March23, 2010. http://www.unep.org/hazardoussubstances/LinkClick.aspx?fileticket=-uYmMOfUPJc%3d&tabid=4325&language=en-US

26 Personal Correspondence with Vera Lucia Anacleto Cardoso Allegro,Director of Environmental and Workers Health, Municiaplity of Sao Paulo,April 30, 2010.

27 Executive Report: Reducing Mercury in Hospital Waste Project, Sino-USCooperation Program, Chemical Registration Center of SEPA, Beijing,September 2007.

28 Workshop for Promoting Mercury Free Health Care Held in Beijing,Global Village of Beijing, December 2009. http://www.mercuryfreehealthcare.org/wsbeijing.pdf

29 The UNDP GEF Global Healthcare Waste Project is being implemented ineight countries by the United Nations Development Program with fundingfrom the Global Environment Facility. The goal of the project is to protectpublic health and the global environment from the impacts of dioxin andmercury releases. The project demonstrates environmentally soundhealthcare waste management practices and best available technologies.http://www.gefmedwaste.org/

30 Personal Correspondence with Twisuk Punpeng, Senior Technical Advisor,Bureau of Technical Advisors, Department of Health, Ministry of PublicHealth, Thailand, May 12, 2010.

31 Personal Correspondence with Silvia Ferrer, Coordinator for EnvironmentalHealth, Ministry of Health, City of Buenos Aires, April 27, 2010.

32 A Report on Market Study on Alternatives of Mercury Measuring Devices inHealth Care in India, Market Insight Consultants, Delhi, January 2009.

33 Research Analysis Report on Mercury Use in China 2003 2005 - TheMeasuring Devices Industry of China, Chemical Registration Center ofState Environmental Protection Administration of China (SEPA),NaturalResources Defense Council, May 2007; Market Research Report onChinese Mercury Free Thermometers and Sphygmomanometers, GlobalVillage of Beijing, November 2007. http://www.chem.unep.ch/MERCURY/Sector-Specific-Information/Docs/China%20-%20GVB%20Non-Mercury%20Medical%20devices%20Report.pdf

34 Workshop for Promoting Mercury-Free Healthcare Held in Beijing, GlobalVillage of Beijing, December 2009. http://www.mercuryfreehealthcare.org/wsbeijing.pdf

35 Dean C. Ripple, Gregory F. Strausse, Selection of Alternatives to Liquid-in-Glass Thermometers,Journal of ASTM International, Vol. 2, No. 9, 2005.

36 Mion D, Pierrin AMG. How accurate are sphygmomanometers? Journal ofHypertension, 12: 245-248 (1998); 9. Markandu NK, Whitcher F, ArnoldA,Carney C. The mercury sphygmomanometer should be abandoned beforeit is proscribed, Journal of Human Hypertension, 14(1): 31-6 (2000).

37 Susan Buchanan, MD, MPH, The Accuracy of Alternatives to MercurySphygmomanometers, Health Care Research Collaborative, Chicago,October 2009. http://www.noharm.org/lib/downloads/mercury/Accuracy_Alts_Mercury_Sphyg_rev10-09.pdf

38 Committee on Emerging and Newly Identified Health Risks, under theDirectorate General for Health and Consumers of the EuropeanCommission, Mercury Sphygmomanometers in Healthcare and the Feasibility ofAlternatives (23 September 2009). http://ec.europa.eu/health/ph_risk/committees/04_scenihr/docs/scenihr_o_025.pdf

39 KEMI, Mercury Free Blood Pressure Measurement Equipment: Experiencesin the Swedish Health Care Sector, Swedish Chemicals Inspectorate,Stockholm, 2005.

40 British Hypertension Society, Validated Blood Pressure Monitors List,http://www.bhsoc.org/blood_pressure_list.stm

Photo Credits:

Cover: Sphygmomanometer and Digital thermometer:

shutterstock.com

Mercury: istockphoto.com

Blood pressure check: Courtesy HCWH SE Asia- photo:

Faye V. Ferrer

Blood pressure device: Courtesy HCWH Latin America

Temperature check Courtesy HCWH SE Asia- photo: Pam

Chua

p. 2: Courtesy HCWH Latin America photo: Juan Manuel

Gonzalez

p. 4: Thermometers, courtesy HCWH

Sphygmomanometer, courtesy HCWH, photo: Jamie

Harvie

p. 5: Courtesy HCWH Latin America

p. 8: Courtesy HCWH SE Asia - photo: Faye V. Ferrer

p. 9: Courtesy, Vernica Umido, Hospital de Nios Ricardo

Gutierrez

p. 10: Courtesy HCWH Latin America

p. 11: istockphoto.com

p. 12: Courtesy Maria Laura Moreno, Centro de Salud Nueva

Esperanza

p. 13: Courtesy HCWH, photo: Jamie Harvie

p. 14: Courtesy HCWH Latin America, photo: Alejandra

Fernandez

p. 15: Courtesy UNDP GEF MedWaste Project, photo: Ashley

Iwanga

p. 16: Courtesy HCWH Latin America, photo: Alejandra

Fernandez

p. 17: Sphgymomanometers courtesy Toxics Link

Mercury Storage, courtesy HCWH Latin America, photo:

Alejandra Fernandez

p. 18: Courtesy HCWH, photos: Jamie Harvie

p. 20: istockphoto.com

p. 21: Courtesy HCWH SE Asia, photo: Faye V. Ferrer

p. 22: Courtesy HCWH SE Asai, photo: Pam Chua


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Global Initiative Advisory Group:

Ravi Agarwal, Executive Director, Toxics Link, India

Yves Chartier, Department for Public Health and Environment, World Health

Organization

Maria Doa, Director, National Program Chemicals Division, Office of

Pollution Prevention and Toxics, U.S. Environmental Protection Agency

Josh Karliner, International Team Coordinator, Health Care Without Harm

Dr. Peter Orris, MD, MPH, Professor and Chief of Service, Environmental

and Occupational Medicine, University of Illinois at Chicago Medical Center

Founding Members and Partners(partial list)

Global

The UNDP GEF Global Healthcare Waste Project

International Council of Nurses

Africa

AGENDA (Tanzania)

GroundWork (South Africa)

Health Department of KwaZulu-Natal (South Africa)

Asia

Baguio General Hospital Fort Del Pilar, Station Hospital at Philippine

Military Academy (Philippines)

Center for Public Health and Environmental Development (Nepal)

General Santos Doctors Hospital (Philippines)

Institute of Public Health Management (Philippines)

Lung Center of the Philippines (Philippines)

Manila Adventist Medical Center and School of Medical Arts (Philippines)

Manipal Hospitals (India)Northern Samar Provincial Government Environment and Natural Resources

Office (Philippines)

Northern Samar Provincial Hospital (Philippines)

Notre Dame de Chartres Hospital (Philippines)

Occupational Health Nurses Association of the Philippines (Philippines)

Ospital ng Maynila (Philippines)

Philippine Childrens Medical Center (Philippines)

Philippine College of Physicians Southern Luzon Chapter (Philippines)

Philippine Heart Center (Philippines)

Philippine Nurses Association (Philippines)

Philippine Public Health Association (Philippines)

Pines City Doctors Hospital (Philippines)

Saint Louis Hospital of the Sacred Heart (Philippines)

San Lazaro Hospital (Philippines)

School of Health Sciences at St. Paul University (Philippines)

School of Health Sciences, Indira Gandhi National Open University (India)

St. Paul Hospitals in Tuguegarao City and Cavite (Philippines)

Toxics Link (India)

University of the Philippines College of Dentistry (Philippines)

Womens Health (Philippines)

Latin America

Center for Analysis and Action on Toxics and their Alternatives (Mexico)

Environmental Health Coordination, Ministry of Health, Government of the

City of Buenos Aires (Argentina)Federico Gmez Childrens Hospital of Mxico (Mexico)

General Regional Hospital No. 1, IMSS Chihuahua (Mexico)

Institute of Health, Central State Hospital, State of Chihuahua (Mexico)

Mexico City Health Secretariat, Federal District (Mexico)

National Institute of Pediatrics (Mexico)

Pediatric Society of Argentina (Argentina)

Regional Hospital No.1, Chihuahua (Mexico)

Toxicology Association of Argentina (Argentina)

Toxicology Unit, General Fernndez Hospital (Argentina)

Toxicology, School of Medicine, University of Buenos Aires (Argentina)

United States

Consorta (United States)

Kaiser Permanente (United States)

Practice Greenhealth (United States)

About the Global InitiativeThe WHO-HCWH Global Initiative to Substitute Mercury-Based Medical devices is a component

of the UNEP Mercury Products Partnership led by the U.S. EPA.



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